Treatment preference changes after exposure to treatment in adults with chronic low back pain.

BACKGROUND: Patients' pretreatment preferences can influence outcomes of nonpharmacologic treatments for musculoskeletal pain. Less is known about how patients' treatment preferences change following exposure to treatment. OBJECTIVE: To examine the effect of exposure to treatment and change in disability and pain on treatment preference ratings of two exercise-based treatments for people with chronic low back pain (LBP). DESIGN: Secondary analysis of a subsample of participants from a randomized clinical trial. SETTING: Academic research setting. PARTICIPANTS: Individuals with chronic LBP (n = 83). INTERVENTIONS: 6 weekly sessions of motor skill training (MST) or strength and flexibility exercise (SFE). MAIN OUTCOME MEASURES: Prior to treatment, participants completed a treatment preference assessment measure (TPA) describing MST and SFE. Participants rated four attributes (effectiveness, acceptability/logicality, suitability/appropriateness, convenience) of each treatment on a 5-point Likert scale (0-4) with higher scores indicating higher ratings. An overall preference rating was calculated as the mean of the attribute ratings. The TPA was administered 12 months post treatment to reassess participants' ratings of the treatment they received. RESULTS: Participants who received MST rated their preference for MST higher 12 months post treatment and participants who received SFE rated their preference for SFE lower. Smaller improvements (to worsening) in pain were associated with a reduction in preference ratings in the SFE group, whereas the MST group generally increased their ratings regardless of pain. Changes in disability were not related to changes in preference ratings. CONCLUSIONS: Participants changed their preference ratings of two exercise-based treatments for LBP after exposure to the treatment. Participants who received the less familiar MST viewed this treatment more favorably 12 months post treatment, and this change was less contingent on changes in disability/pain than for participants in the SFE group. Assessing preference ratings at various times during treatment is crucial to understand a person's preference for and perceptions of a treatment.

Motor skill training versus strength and flexibility exercise in people with chronic low back pain: Preplanned analysis of effects on kinematics during a functional activity.

BACKGROUND: People with chronic low back pain display the altered movement pattern where the lumbar spine moves more readily into its available range of motion relative to other joints. A logical approach to treatment, therefore, would be to improve this pattern during functional activities. METHODS: 154 participants were randomized to receive 6 weeks of motor skill training or strength and flexibility exercise. Participants in the motor skill training group received person-specific training to modify their altered movement pattern during functional activities. Participants in the strength and flexibility group received exercises for trunk strength and trunk and lower-limb flexibility. At baseline, post-treatment and 6-months after treatment participants performed a test of picking up an object using their preferred pattern. Three-dimensional marker co-ordinate data were collected. A mixed-model repeated measures analysis of variance was used to examine the treatment group and time effects. FINDINGS: Motor skill training: Baseline early excursion values [mean (confidence interval)] were as follows: knee = 11.1°(8.0,4.1), hip = 21.2°(19.2,23.1), lumbar = 11.3°(10.4,12.3). From baseline to post-treatment significant improvements in early excursion included: knee = +18.6°(15.4,21.8), hip = +10.8°(8.8,12.8), and lumbar = -2.0°(-0.1,-4.0). There were no significant changes from post-treatment to 6-month follow-up. Strength and flexibility exercise: Baseline early excursion values were as follows: knee = 8.9°(5.8,11.9), hip = 20.8°(18.9,22.8), and lumbar = 11.2°(10.3,12.2) early excursion. There were no significant changes for knee, hip, and lumbar early excursion. INTERPRETATION: Motor skill training was more effective than strength and flexibility exercise at changing and maintaining change to the altered movement pattern during a functional activity test of picking up an object.

Consistent differences in lumbar spine alignment between low back pain subgroups and genders during clinical and functional activity sitting tests.

BACKGROUND: Subgroups of people with low back pain display differences in their lumbar alignment during tests from a clinical examination. However, it is unknown if subgroups display the same patterns during a functional activity test and if gender influences subgroup-related differences. OBJECTIVES: Test if differences in lumbar alignment between two LBP subgroups are 1) present during a functional activity test of preferred sitting and 2) independent of gender. DESIGN: Cross-sectional. METHOD: 154 participants with chronic low back pain were classified based on the Movement System Impairment Classification System by a physical therapist. Participants performed a functional activity test of preferred sitting and clinical tests of maximum flexed and extended sitting. 3D marker co-ordinate data were collected. Sagittal plane lumbar alignment, indexed by lumbar curvature angle, was calculated. A three-way mixed effect analysis of variance was used to examine effects of test, subgroup, gender, subgroup × test, gender × test and subgroup × gender. RESULTS/FINDINGS: The lumbar rotation with extension subgroup [LCA = -8.0° (-9.5,-6.5)] displayed a more extended lumbar alignment than lumbar rotation [LCA = -5.9° (-7.4,-4.4)]. Women [LCA = -10.7° (-12.3,-9.2)] displayed a more extended lumbar alignment than men [LCA = -3.2° (-4.7,-1.7)]. There was a significant gender × test interaction (p = 0.01). The subgroup × test (p = 0.99) and subgroup × gender (p = 0.76) interactions were not significant. CONCLUSIONS: LBP subgroup differences in lumbar alignment are present during preferred sitting. Gender-related differences in lumbar alignment are not driving subgroup differences. These findings highlight the need to use patient-specific clinical characteristics to guide treatment of a functional activity of preferred sitting limited due to low back pain.

Clinical and Psychosocial Factors Over Time Following an Acute Low Back Pain Episode.

BACKGROUND: Low back pain (LBP) is a prevalent condition with overwhelming healthcare costs and high disability rates. Characterization of clinical and psychosocial variables over time in patients experiencing an episode of acute LBP and the identification of factors that differ between those who develop chronic LBP and those who do not could aid in the development of improved targeted treatment. PURPOSE: The purpose of this study was to evaluate the trajectory of depression, pain catastrophizing, life purpose, pain sensitivity, and disability in persons presenting with an acute/subacute episode of LBP, evaluating whether there are changes over time and differences in these variables between those who developed chronic LBP and those who did not. METHODS: Prospective analysis (baseline, 2.5 months, 6 months, and weekly diaries) of 42 patients experiencing an acute LBP episode was performed. Descriptive statistics, repeated-measures mixed modeling, and Fisher's least significant differences method were used during data analysis. RESULTS: Depressive symptoms vary over time. There was no difference over time in pain catastrophizing, life purpose, pain sensitivity, or disability. Those who met the criteria for chronic LBP at 6 months had increased pain catastrophizing scores and higher disability scores compared with those who do not meet the criteria for chronic LBP. Depressive symptoms, life purpose, and pain sensitivity were not different between those who met the criteria for chronic LBP and those who did not. CONCLUSION: Findings from this study characterize factors potentially contributory to the development of chronic LBP over time. Those participants who developed chronic LBP had higher pain catastrophizing scores averaged across all time points in this study, suggesting it could be an interesting factor to target to improve LBP chronicity.

The relationship between indicators of lumbo-pelvic coordination and pain, disability, pain catastrophizing and depression in patients presenting with non-chronic low back pain.

This study examined associations and changes overtime in low back kinematics and disability, pain, pain catastrophizing, and depression and assessed whether associations and changes overtime varied between individuals who meet the classification criteria for chronic low back pain at 6 months and those who do not. Findings suggested that those persons with a higher ratio of lumbar contribution to thorax motion and smaller pelvic tilt during forward bending had higher scores on measures of disability, pain and pain catastrophizing. This same association was found in those who met classification criteria for chronic low back pain at 6 months. Opposing associations were found in the group not meeting classification criteria for chronic low back pain, specifically, increased pelvic tilt was positively associated with higher pain catastrophizing scores. Practitioner summary This study examined associations and changes overtime in low back kinematics and psychosocial and clinical factors and whether associations and changes overtime varied between individuals who meet the classification criteria for chronic low back pain at 6 months and those who do not, Results suggest that associations exist between psychological factors and kinematic changes during the time between an acute low back pain episode to meeting classification for chronic low back pain at 6 months.

The Effects of Pain Severity, Pain Catastrophizing, Depression, and Exercise on Perceived Disability in Acute Low Back Pain Patients.

Background/Purpose: The effectiveness of cognitive treatments for low back pain, a prevalent and costly condition, are commonly based on the principles of the Cognitive Behavioral Model of Fear of Movement/(Re)injury. In this model, persons with a painful injury/experience who also engage in pain catastrophizing are most likely to avoid activity leading to disability. The validation of this model in patients with acute low back is limited. The purpose of this project was to examine the relationship of perceived disability with variables identified in the Cognitive Behavioral Model of Fear of Movement/(Re)injury such as, pain severity, pain catastrophizing, depression, and exercise in persons with acute low back pain. Methods: A multiple linear regression model was used to assess the association of perceived disability with pain severity, pain catastrophizing, depression, and exercise at baseline among subjects with acute low back pain (N = 44) participating in a randomized clinical trial to prevent transition to chronic low back pain. Results: Controlling for age, the overall model was significant for perceived disability (F[5, 35] = 14.2; p < .001). Higher scores of pain catastrophizing (p = .003) and pain severity (p < .001) were associated with higher perceived disability levels. Exercise and depression were not significantly associated with perceived disability. Implications: The use of the Cognitive Behavioral Model of Fear of Movement/(Re)injury in acute LBP patients is appropriate; because this model is commonly used as rationale for the effectiveness of cognitive treatments, these findings have clinical relevance in the treatment of this condition.

MODIFYING STANCE ALTERS THE PEAK KNEE ADDUCTION MOMENT DURING A GOLF SWING.

BACKGROUND: The knee joint is one of the most frequently injured regions in the game of golf, and the loads experienced by the knee during the golf swing are typically greater than during other activities of daily living. Altering movement patterns is a common strategy that can be used to reduce loading on the knee joint but has received little attention during studies of the golf swing. The primary aim of this study was to examine the effect altering golf stance has on the lead limb peak external knee adduction moment. STUDY DESIGN: Laboratory based, quasi-experimental. METHODS: Twenty healthy participants were recruited for a 3-dimensional biomechanical analysis wherein participants hit three golf shots with a driver using the following stance conditions: self-selected, bilateral 0 º foot angle, bilateral 30 º foot angle, wide stance width, and narrow stance width. RESULTS: Both the 30 º foot angle (0.80 ± 0.51 Nm) and wide stance width (0.89 ± 0.49 Nm) conditions significantly decreased (p < 0.001) the lead limb peak external knee adduction moment compared to the self-selected (1.15 ± 0.58 Nm) golf stance. No significant differences (p = 0.109) in swing speed were found between any of the stance conditions. CONCLUSION: The externally rotated foot position and wider stance width decreased the lead limb peak external knee adduction moment without hindering swing speed. Modifying stance could be a viable option for golfers who wish to continue playing the sport at a high level, while reducing potentially detrimental loads at the knee joint.Levels of Evidence: 2b-Individual cohort study.

Mechanical demands on the lower back in patients with non-chronic low back pain during a symmetric lowering and lifting task.

There is limited information in the literature related to the lower back loading in patients with LBP, particularly those with non-chronic LBP. Toward addressing such a research gap, a case-control study was conducted to explore the differences in lower back mechanical loads between a group of females (n=19) with non-chronic, non-specific LBP and a group of asymptomatic females (n=19). The differences in lower back mechanical loads were determined when participants completed one symmetric lowering and lifting of a 4.5kg load at their preferred cadence. The axial, shearing, and moment components of task demand at the time of peak moment component as well as measures of peak trunk kinematics were analyzed. Patient vs. asymptomatic group performed the task with smaller peak thoracic rotation and peak lumbar flexion. While no differences in the moment component of task demand on the lower back between the patients and controls were found, the shearing (40-50 age group) and axial components of task demand were, respectively, larger and smaller in patients vs. CONTROLS: Whether alterations in lower back loads in patients with non-chronic LBP are in response to pain or preceded the pain, the long-term exposure to abnormal lower back mechanics may adversely affect spinal structure and increase the likelihood of further injury or pain. Therefore, the underlying reason(s) as well as the potential consequence(s) of such altered lower back mechanics in patients with non-chronic LBP should to be further investigated.

Comparison of lumbo-pelvic kinematics during trunk forward bending and backward return between patients with acute low back pain and asymptomatic controls.

BACKGROUND: Prior studies have reported differences in lumbo-pelvic kinematics during a trunk forward bending and backward return task between individuals with and without chronic low back pain; yet, the literature on lumbo-pelvic kinematics of patients with acute low back pain is scant. Therefore, the purpose of this study was set to investigate lumbo-pelvic kinematics in this cohort. METHODS: A case-control study was conducted to investigate the differences in pelvic and thoracic rotation along with lumbar flexion as well as their first and second time derivatives between females with and without acute low back pain. Participants in each group completed one experimental session wherein they performed trunk forward bending and backward return at self-selected and fast paces. FINDINGS: Compared to controls, individuals with acute low back pain had larger pelvic range of rotations and smaller lumbar range of flexions. Patients with acute low back pain also adopted a slower pace compared to asymptomatic controls which was reflected in smaller maximum values for angular velocity, deceleration and acceleration of lumbar flexion. Irrespective of participant group, smaller pelvic range of rotation and larger lumbar range of flexion were observed in younger vs. older participants. INTERPRETATION: Reduced lumbar range of flexion and slower task pace, observed in patients with acute low back pain, may be the result of a neuromuscular adaptation to reduce the forces and deformation in the lower back tissues and avoid pain aggravation.